Coast Guard Issues ‘Final Action Memo’ on El Faro Investigation

From gcaptain: Coast Guard Issues ‘Final Action Memo’ on El Faro Investigation

the primary cause of the casualty was the decision to navigate El Faro too close to the path of Hurricane Joaquin.

contributing factors include: (1) an ineffective safety management system within the operating company, TOTE Services, Incorporated; (2) American Bureau of Shipping’s failures to uncover or otherwise resolve longstanding deficiencies that adversely affected the safety and seaworthiness of vessels on multiple occasions; and (3) failure of the Coast Guard to adequately oversee the third party in this case, and the investigation reveals that the Coast Guard has not sustained the proficiency and policy framework to do so in general.

Here is a link to the CG Memo

  1. While many factors contributed to this marine casualty, by far the most prominent was the Master’s decision to sail the ship in close proximity to a Category 3 hurricane. There were multiple opportunities to take alternate, safer routes as the storm approached. There was adequate information available regarding the threat posed by hurricane Joaquin, despite the unusually unpredictable nature of the storm’s path and intensity. There were warnings and recommendations from the mates on successive watches to alter course to avoid the storm, but they were not heeded. The combination of these actions and events placed the EL FARO in harm’s way near the eye of the storm, and subjected her to wind and sea conditions that prudent mariners avoid. In the case of the ELF ARO, those conditions led to a chain of events, the effects of which were irreversible.

According to TS l’s former Designated Person Ashore (DPA), the company deliberately abandoned the practice of assisting masters with heavy weather voyage planning, storm system monitoring, and avoidance. 1 Understanding that the company routinely provided liner service in an area prone to hurricanes during hurricane season, the decision to abandon such a crucial support system is irresponsible and inexcusable.

I’d like to see the USCG ask the UK MAIB to do a peer review of the El Faro incident, and of the USCG/NTSB investigation.


“I concur with the intent of…”

Are these weasel words?

  1. The Coast Guard received one comment that took issue with the RO!language
    that cited the VDR transcript, stating "{a]t 5:55 AM, the CIM called the Master
    on a UHF radio and reported a flooded hold on the starboard side with knee deep
    water. " The commenter notes that this incorrectly suggests that the Chief Mate
    was reporting that the level of water in the hold was knee deep. The actual quote
    from the VDR transcript starting at 05:55:00.4 is: “(ya got) water against the
    side just enough to (go/throw/pour) over the edge of scuttle about knee deep (in
    here) water (rolls) right over.” It is clear from this that he is referring to there
    being knee deep water on the starboard side on Second Deck, and that water was
    high enough (knee deep) to allow it to pour over the edge/coaming of the scuttle
    and into Hold 3. The commenter requests that the ROI be corrected. The Coast
    Guard does not concur with this comment. The language is quoted directly from
    the EL FARO VDR, and was not taken out of context within the ROI.

I’m inclined to agree with the commenter on this (without having searched back through the context).

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Capt Davison had a system for dealing with hurricanes. That system was to review the wx on the computer using the BVS program during working hours. That approach did not work with Joaquin because of the 1 in 100 forecast errors (according to the NHC) and the fact that changes occurred during the night.

A better system, the one used everywhere I’ve been is to have the bridge watch monitor the forecasts on a 24 hrs basis.

Tote had a system for hiring and monitoring the ship captains. Likewise Tote’s system failed in the hiring and monitoring of Davison. Davison’s combination of over confidence, reluctance to engage the crew and poor understanding of the nature of hurricanes is also maybe 1 in 100, or maybe less.

I’m inclined to concur with a number of comments that the Zumwalt disagreed with, most notably #49, 55, 52 and 50!! (to name just a few)

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Out at sea, with falling glass,
Soundly sleeps the careless ass.
Only when it’s high and rising,
Truly rests the careful wise one.


It will take more than a sinking and loss of 33 lives before USCG Commander think it necessary to mandate enclosed lifeboats apparently:


How does anyone view a tropical cyclone (or any dynamic weather system, for that matter) as a 9-5 thing that shuts down after working hours? I guess we know the answer to that one.

This is an issue that truly vexes me. The open lifeboats should be gone. Period. No arguments, no more grandfathering. If you can’t afford then you ought not own and operate a ship. An enclosed, stern-launched boat would have given them a damned good fighting chance.


Here is another US mariner voicing his opinion on open lifeboats:

In my opinion nothing but free fall lifeboats should be allowed on new ships, except where it is impossible to fit them for technical or operational reasons.

Even if impossible to fit free-fall lifeboats, enclosed lifeboats should be mandatory on all ships operating outside coastal areas, regardless of age of vessel.


That will never happen until Lockheed or Boeing or one of the other congressional paymasters opens a lifeboat factory in Mexico.


Gee I would have never suspected that Davison was at fault.

There is no clearer confirmation of USCG incompetence than its pseudo-professional “judgment” that enclosed lifeboats are unnecessary.

No other responsible maritime expert or maritime authority anywhere else in the world shares the USCG’s antiquated pre-WW II opinion.

What could possibly be the argument against requiring enclosed lifeboats? Saving the owners of a handful of old obsolete ships in no better condition than the EL FARO that still have open lifeboats a few pennies?

Any competent USCG inspector should realize instantly that when he boards a ship that has owners that are too cheap to provide enclosed lifeboats, that the owners are also too cheap to properly maintain anything else, and the ship is the next EL FARO or MARINE ELECTRIC waiting to happen.

Open lifeboats should ring alarm bells in any inspector’s head that the ship needs a very intensive inspection.


I suggest that somebody inquires with this heroic government official what specific number of drowned seamen is required to invoke them to finally take action to obtain safer lifeboats? Is it 60, 80 or more?


A new lifeboat and davit costs hundreds of thousands of dollars.

Escape capsules would be nice as well.

So what. On a ship that burns $10,000 a day in fuel, and has 10,000 a day in wages and benefits, and costs millions to put through drydocking and inspection, $200,000 is not much money.

The egg shaped “escape capsules” are full enclosed, insulated, and reliable. They cost more than a life raft, but when you consider that they don’t have to be tested, inspected, and repacked every year, after a few years the lifecycle cost becomes less than a Liferaft. Given that Canadian fishing boats and tugs (I can even think of a couple US tugs that have them), can afford the escape capsules, so too can US ships.

In fact, I would say that most inflatable liferafts should be replaced by escape capsules.


If you are referring to the Whittaker Capsules that was all the rage on American owned rigs and fixed platforms back in the 1970’s and 80’s I disagree:
Have you tried to operate these things, even in a duck pond?